Remote Nursing Certified Practice

Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

This assessment is based on best practice as of January 2010. For more information or to provide feedback on this or any other decision support tools, e-mail certifiedpractice@crnbc.ca

Adult Cardio-Respiratory Assessment

Nurses with remote nursing certified practice designation are able to manage the following respiratory condition: Acute bronchitis The following assessment must be completed and documented. As a complete respiratory exam includes a cardiovascular exam, these two examinations have been combined.

ASSESSMENT
History of Present Illness and Review of Systems
General The following characteristics of each symptom should be elicited and explored: Onset sudden or gradual Location - radiation Duration frequency, chronology Characteristics quality, severity Associated Symptoms Aggravating and precipitating factors Relieving factors Current situation (improving or deteriorating) Effects on ADLs Previous diagnosis of similar episodes Previous treatments and efficacy of Cardinal Signs and Symptoms In addition to the general characteristics outlined above, additional characteristics of specific symptoms should be elicited, as follows: Cough Quality (e.g., dry, hacking, loose, productive) Severity Timing (e.g., at night, with exercise, in cold air, outside or inside) Duration: greater than 2 weeks (screen for TB) Sputum Colour Amount (in teaspoons, tablespoons, cups) Consistency Purulence, odour, foul taste Time of day, worse Hemoptysis Amount of blood Frank blood or mixed with sputum Association with leg pain, chest pain, shortness of breath
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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

Shortness of Breath Exercise tolerance (number of stairs client can climb or distance client can walk) Relation to posture Orthopnea (number of pillows used for sleeping) Shortness of breath at rest Association with paroxysmal nocturnal dyspnea (waking up out of sleep, acutely short of breath; attack resolves within 20 to 30 minutes of sitting or standing up) Associated swelling of ankles or recent weight gain Cyanosis Observation of blue colour of the lips or fingers (under what circumstances, when first noted, recent change in this characteristic) Wheeze Timing (i.e., at rest, at night, with exercise) Chest Pain (see table 1) Associated symptoms (i.e., faintness, shortness of breath, nausea) Relation to effort, exercise, meals, bending over Explore the pain carefully. Include quality, radiation, severity, timing, quality. Fainting or Syncope Weakness, light-headedness, loss of consciousness Relation to postural changes, vertigo or neurological symptoms Extremities Edema: - site (i.e., in dependent body parts) - relation of edema to activity or time of day Intermittent claudication (exercise-induced leg pain) - distance client can walk before onset of pain related to claudication - time needed to rest to relieve claudication - temperature of affected tissue (warm, cool or cold) Tingling Leg cramps or pain at rest Presence of varicose veins Other Associated Symptoms Fever Malaise Fatigue Night sweats Weight loss Palpitations Nausea and vomiting GI Reflux

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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

Medical History (Specific to Cardio-respiratory Systems) Allergies Medications currently used (prescription and over the counter [e.g., angiotensin-converting enzyme (ACE) inhibitors, -blockers, ASA, steroids, nasal sprays and inhaled medications (puffers, antihistamines, estrogen, progesterone, diuretics, antacids, steroids, digoxin)] Herbal/traditional preparations Immunizations (e.g., pneumococcal, annual influenza) Disorders: - Frequency of colds and treatment used, nasal polyps, chronic sinusitis - Asthma, bronchitis, pneumonia, chronic obstructive pulmonary disease (COPD), tuberculosis (TB) (disease or exposure), cancer, cystic fibrosis - Dyslipidemia, hypertension, diabetes mellitus, thyroid disorder, chronic renal disease, systemic lupus erythematosus - Coronary artery disease, angina, myocardial infarction - Cardiac murmurs, valvular heart disease - Recent viral illness, history of rheumatic fever Seasonal allergies Presence of symptoms of gastro-oesphageal reflux disease (GERD) Admissions to hospital and/or surgery for respiratory or cardiac illness Date and result of last Mantoux test and chest x-ray Blood transfusion Family History (Specific to Cardio-respiratory Systems) Others at home with similar symptoms Allergies, atopy Asthma, lung cancer, TB, cystic fibrosis Diabetes mellitus Heart disease: hypertension, ischemic coronary artery disease, MI (especially in family members < 50 years of age), sudden death from cardiac disease, dyslipidemia, hypertrophic cardiomyopathy Personal and Social History (Specific to Cardio-respiratory Systems) Smoking history (number of packages/day, number of years) Exposure to second hand smoke, wood smoke Substance use alcohol, caffeine, street drugs, including injection drugs, cocaine, steroids Occupational or environmental exposure to respiratory irritants (mining, forest fire fighting) Exposure to pets Crowded living conditions Poor personal or environmental cleanliness Institutional living Injection and inhaled drug use Alcohol use HIV risks Mold Obesity High stress levels (personal or occupational)

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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

PHYSICAL ASSESSMENT
Vital Signs Temperature Pulse Respiratory rate Blood pressure Sp02 General Appearance Acutely or chronically ill Degree of comfort or distress Position to aid respiration (e.g., tripod) Diaphoresis Ability to speak a normal-length sentence without stopping to take a breath Colour (e.g., flushed, pale, cyanotic) Nutritional status (obese or emaciated) Hydration status Inspection Colour (e.g., central cyanosis) Shape of chest (e.g., barrel-shaped, spinal deformities) Symmetry of chest movement Rate, rhythm and depth of respiration, respiratory distress Use of accessory muscles (sternocleidomastoid muscles) Intercostal indrawing Evidence of trauma Chest wall scars, bruising, signs of trauma Clubbing of the fingers Precordium: visible pulsations Jugular venous pressure Color of conjunctiva Extremeties - Hands - edema, cyanosis, clubbing, nicotine stains, cap refill (<3 seconds) - Feet and legs - changes in foot colour with changes in leg position (i.e., blanching with elevation, rubor with dependency), ulcers, varicose veins, edema (check sacrum if client is bedridden), colour (pigmentation, discoloration), distribution of hair Skin - rashes, lesions, xanthomas Palpation Tracheal position (midline) Chest wall tenderness Respiratory Excursion Tactile fremitus Spinal abnormality Nodes (axillary, supraclavicular, cervical) Masses Subcutaneous emphysema Apical beat:
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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

- PMI normally located at the fifth intercostal space, mid-clavicular line - Assess quality and intensity of apical beat normal, diffuse, weak, forceful, heave - Apical beat (PMI) may be laterally displaced, which indicates cardiomegaly Identify and assess pulsations and thrills (palpable murmur that feels like a purr) in aortic, pulmonic, mitral and tricuspid areas, along left and right sternal borders, in epigastrium and along left anterior axillary line Hepatomegaly, RUQ tenderness Peripheral pulses - Check for presence, rate, rhythm, amplitude and equivalence of peripheral pulses, (radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis) - Check for synchrony of radial and femoral pulses Edema: pitting (rated 0 to 4) and level (how far up the feet and legs the edema extends); sacral edema Skin: temperature, turgor, texture

Percussion of lung fields Resonance - Increased resonance over hyperinflated areas (e.g., asthma, emphysema) - Dullness to percussion over areas of consolidation (e.g., pneumonia, pleural effusion and collapsed lung) Location and excursion of the diaphragm Auscultation of lungs Assist client to breathe effectively Listen for sounds of normal air entry before trying to identify abnormal sounds Degree of air entry throughout the chest (should be equal) Quality of breath sounds (e.g., bronchial, bronchovesicular, vesicular) Ratio of inspiration to expiration (prolonged expiration in asthma, COPD) Adventitious Sounds: - Wheezes (aka rhonchi): continuous sounds, ranging from a low-pitched snoring quality to a high-pitched musical quality, may be inspiratory or expiratory, or both, may clear with coughing, may be present only on forced expiration. - Crackles (aka rales): discrete, crackling sounds heard on inspiration, may clear with coughing. May be fine (high-pitched, short popping sounds) or coarse (low-pitched, bubbling and gurgling sounds). Diffuse in severe pneumonia, bronchiolitis, CHF. Localized in bronchiectasis and pneumonia. - Pleural rub: a coarse, creaking sound from pleural irritation, heard on inspiration or expiration - Stridor: high-pitched, inspiratory, crowing sound louder in the neck. - Pleural rub: pneumonia, effusion - Decreased breath sounds: pneumonia, atelectasis, pleural effusion, pneumothorax Auscultation of heart Listen to normal heart sounds before trying to identify murmurs. Use diaphragm of stethoscope first, then bell of stethoscope, when listening to the heart Auscultate at aortic, pulmonic, Erbs point, tricuspid, and mitral. Attempt to identify: - Rate and rhythm. - S1 and S2 sounds and their intensity - Added heart sounds (S3 and S4), rubs, splitting of S2 - Murmurs: determine location (where murmurs are best heard), radiation, their timing in cardiac cycle, intensity (grade; seeTable 1) and quality Auscultate carotid arteries, abdominal aorta, renal arteries, iliac arteries, and femoral arteries for bruits

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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

Table 1. Grade of Heart Murmur Grade I II III IV V VI Characteristics Very quiet, barely audible Quiet but audible Easily heard Thrill can be felt, murmur is easily heard Thrill can be felt and loud murmur can be heard with stethoscope placed lightly on chest Thrill can be felt and very loud murmur can be heard with stethoscope held close to chest wall

Associated Systems Ear, Nose, Throat A complete respiratory assessment includes the ENT system.

CLINICAL REASONING AND CLINICAL JUDGMENT

The first step is to differentiate between acute respiratory distress and respiratory conditions that can be managed safely by certified practice nurses. The following signs and symptoms require immediate referral to a physician or nurse practitioner: Severe dyspnea Unable to lay flat Inability to speak or fragmented speech Tracheal shift Unrelieved chest pain Unable to maintain Sp02 greater than > 92% on room air Severe increasing fatigue Cyanosis (central cyanosis is not detectable until SaO2 is less than 85%) Silent chest or crackles throughout lung fields Decreased level of consciousness Diminishing respiratory effort Nasal flaring or tug Intercostal indrawing Pulsus paradoxus Pitting edema of extremities Recent MI Recent hospitalization for Congestive Heart Failure (CHF)

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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

DIAGNOSTIC TESTS:
The certified practice nurse may consider the following diagnostic tests in the examination of the cardiorespiratory system to support clinical decision making: - ECG - Hemoglobin - Cardiac troponins

The certified practice nurse can utilize the following decision support tools to guide decision-making and manage the respiratory condition: Acute bronchitis.

REFERENCES
Ahmend, A., Graber, M., & Dickson, E. (2009). Evaluation of the adult with dyspnea in the emergency department. Uptodate.com. Retrieved September 16, 2009 http://uptodateonline.com/online/content/topic.do?topicKey=adult/6520&selectedTitle=10~150&source=search _result#11 Dugani, S., & Lam, D. (Eds.). (2009). The Toronto Notes 2009 Comprehensive Medical Reference & Review for MCCQE 1 & USMLE II. Toronto, Canada: Toronto Notes for Medical Students, Inc. Jarvis, C. (2009). Physical examination and health assessment: First Canadian Edition. Toronto, Ont: Elsevier Canada. Leblond, R., Brown, D., & DeGowin, R. (2009). DeGowins diagnostic examination. New York: McGraw-Hill Medical. Provincial Emergency Services Project (PESP). (2006). Acute asthma management toolkit. Vancouver Island Health Authority. Retrieved September 16, 2009 from https://intranet.viha.ca/departments/emergency/Documents/policies/asthma_toolkit_s_island.pdf Uphold, C., & Graham, M. (2003). Clinical guidelines in family practice. Florida, USA: Barmarrae Books, Inc.

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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

Appendix 1

(PESP, 2006, p. 7)

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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

Characteristic of Chest Pain

Myocardial Infarction or Acute Coronary Insufficiency

Angina

Pneumonia

Pulmonary Embolism (Chest pain may be absent in pulmonary embolism)

Pericarditis

MSK Disorder

Esophageal, Gastric or Duodenal

Stress or Emotional Disorder

Bronchitis

Dissecting Aortic Aneurysm

Onset

Sudden, patient With exertion at rest

Gradual or sudden

Sudden

Gradual or sudden

Gradual or sudden Anterior, lateral and/or posterior chest wall

Disorder Gradual or sudden Retrosternal, epigastric, left chest, left or right upper quadrant

Gradual or sudden Gradual

Sudden

Location

Retrosternal, anterior chest

Retrosternal, anterior chest

Anterior, lateral and/or posterior lung field(s)

Retrosternal, lateral chest

Retrosternal,

Variable; anterior chest, left chest

Muscular walll

Anterior chest, abdominal or in back.

anterior chest, anterior chest

ache in chest may be

Radiation

Left arm, left jaw, back,

Left arm, left jaw, back,

Anterior chest, shoulder,

Variable

Variable: shoulder tip, neck

Arm, shoulder, May be felt in back Usually none neck, back, abdomen or arm

Usually none Often radiates to thoracic back

shoulder, neck, shoulder, neck,

upper abdomen upper abdomen neck Duration > 20 min < 1-2 min Hours Variable Hours to days Minutes or hours Minutes or hours Minutes or hours Hours to days, usually with coughing Intensity Severe Mild to moderate Moderate Absent or mild to moderate Quality Sensation of squeezing, pressure Sensation of tightness, pressure Constant ache, with intermittent knife-like pain Dull ache; knifelike pain may also be present Usually moderate, but may be severe Sharp Dull ache; also be present Burning (usually), Achy, stabbing Aching Knifelike, tearing. May be nagging. Mild to moderate Moderate Mild to moderate Mild to moderate Excruciating. Hours

sharp pain may tightness

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Adult Decision Support Tools: CARDIO / RESPIRATORY ASSESSMENT

Characteristic of Chest Pain

Myocardial Infarction or Acute Coronary Insufficiency

Angina

Pneumonia

Pulmonary Embolism (Chest pain may be absent in pulmonary embolism)

Pericarditis

MSK Disorder

Esophageal, Gastric or Duodenal

Stress or Emotional Disorder

Bronchitis

Dissecting Aortic Aneurysm

Relief

None

Rapid relief with rest and/or sublingual nitroglycerin

None

None

Sitting up and leaning forward often helps; other changes in position may alter the pain

Rest, mild analgesics

Antacids, milk, sitting up or standing up

Rest, relaxation, distraction

Rest, control None of cough

Precipitating or None may be aggravating factors obvious

Exertion, heavy Increased meal, walking cold wind pain with deep inspiration; recently ill with a cold uphill against a coughing or

Immobilizatio Previous n; none may be obvious; pain may be worse with deep inspiration or coughing infection of upper pain worse with deep inspiration or coughing

History of unaccustomed physical work;

Certain foods, a over; pain may awaken person occur when stomach is empty

Stressful

Cough

Aortic aneurysm (often unknown).

large meal, bending situations, fatigue

respiratory tract; pain worse

with arm action from sleep and may

Associated signs and symptoms

Nausea, sweating, shortness of breath, anxiety, palpitations

Typically none

Fever, cough, sputum, shortness of breath

Shortness of breath, sweating, hemoptysis, leg pain (rare

Symptoms of infection of upper respiratory tract may be present; occurs in younger adults

Localized chestwall tenderness, tender costochondral

Regurgitation of acid in mouth, swallowing, sticking sensation when food swallowed, cough (rare); test of stool for occult blood may be positive

Tightness in neck and shoulder(s), reduced appetite, mild weight loss, fatigue, sleep disturbance, palpitations, dizziness, hyperventilation symptoms

Malaise, fever, long standing productive cough, possibly wheezes in chest

Widening pulse pressure, dissociation of brachial blood pressures, absent pulses, paralysis, pulsus paradoxus, aortic insufficiency murmur.

belching, difficulty headaches,

malaise; usually area

Adapted from First Nations and Inuit Health Branch, 2006. Clinical Practice Guidelines for Nurses in Primary Care.
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